Author: Renee Reynolds, MD
The 2012 statement of the CNS, AANS, ABNS, and SNS on Ensuring an Adequate Neurosurgical Workforce for the 21st Century, highlights the challenges organized neurosurgery faces for the future. It is clear that maintaining an adequate supply of competent neurosurgeons to provide quality healthcare for Americans is in jeopardy. Factors including the aging population improved insurance coverage for Americans, and the evolution of new and novel treatment options in our field are driving the need for quality neurosurgical care. Just as important, however, are training factors, including the minimal growth in supply to satisfy this large increase in demand. These challenges, coupled with the lengthy training process necessary to obtain competence, difficulty recruiting new providers to our rigorous specialty, and the lack of appropriate alternative providers to treat neurosurgical conditions, further threaten any resolve. Lastly, there is the silent but real menace of burnout that spreads an invisible layer of suppression upon possible progress in this arena.
Burnout is a psychological state coined by Christina Maslach in the 1970s characterized by the three cardinal symptoms of emotional exhaustion, depersonalization, and reduced personal accomplishment.1 Recent studies show that more than half of physicians in the United States experience burnout (54.4%), a much higher rate than the general working population (28.4%).2 This high level of burnout seen among physicians is likely multifactorial. Many of the characteristics that lead to our success also put us at risk, including the common type A personality and a perfectionist, workaholic mentality. The invisible weight of caring for sick patients, escalating documentation requirements, challenges maintaining a work-life balance, and the impending legal ramifications of our decisions are further pushing the pendulum towards burnout.
Residents have the additional burden of a high level of responsibility coupled with a low level of control, making them further susceptible to burnout. Pairing this with the lengthy and emotionally challenging nature of neurosurgical training, most would hypothesize the neurosurgical burnout would equal or exceed averages among all specialties. Recent studies, however, showed a national survey of neurosurgical trainees reporting a prevalence of only 36.5%.3 Should we applaud ourselves over this relatively low prevalence, basking in the possibility that our field has recruited more resilient individuals? Is this number even reliable or purely a byproduct of a subliminal but potent mentality within competitive specialties to never show weakness? Or does it even matter? Even if accurate, a third of our trainees are experiencing burnout prior to transitioning to independent practice. With an already suboptimal ratio of neurosurgeons to persons, and a stagnant 160 trainees graduating yearly, burnout poses a powerful hazard to the future neurosurgical workforce.4
In the setting of burnout, everyone pays a price. This includes patients, with burnout leading to notable increases in medical errors and malpractice rates, as well as lower patient compliance. Burnout has also been linked to diminished patient satisfaction attributed to decreases in physician professionalism and engagement. There are threats to the personal health of our trainees, with elevated rates of depression, suicidal ideation, insomnia, and substance abuse all of which are elevated in a state of burnout.5 Families also suffer, as the effects of burnout suffocate the remaining physical and emotional energy one has left when returning home from the workplace.
Even more worrisome is the relative unspoken nature of these serious issues and the lack of solutions to skillfully address them. The difference between stress and burnout is considered the ability to recover during your time off; however, neurosurgical residents facing the demands of years in apprenticeship and a profession that demands competence and perfection often lack the freedom to recognize burnout and resolve it with time away. The medical community suggests education about burnout, workload modifications, stress management training, emotional intelligence training, and wellness workshops as solutions to address burnout in training. Logistically, however, this is nearly impossible and likely underestimates what is necessary to combat this epidemic. Such education would compete with both the limited allotted time to gain proficiency in our complex specialty in the era of duty hour restrictions and the minimal time off trainees have to re-energize themselves. Minimizing workload is nearly impossible in a system where residents remain a central asset to the continuous service provided to health care systems in support of neurosurgical patients. And where does the responsibility even fall? Is it at the program level, the administration, the graduate medical education office? Overall it is clear that resident (and truly physician) burnout matters. The less crystal discussion revolves around the resolutions which remain in their infancy and are poorly defined. Our residents, as well as our profession as a whole, are in crisis. Unless changes in the healthcare system and training processes occur, including addressing the subliminal factor of burnout, these crises will persist. The conversations to address this need to start now.
>IN THE SETTING OF BURNOUT, EVERYONE PAYS A PRICE. THIS INCLUDES PATIENTS, WITH BURNOUT LEADING TO NOTABLE INCREASES IN MEDICAL ERRORS AND MALPRACTICE RATES, AS WELL AS LOWER PATIENT COMPLIANCE.<
- Maslach C., & Jackson, S.E. (1981). The Measurement of Experienced Burnout. Journal of Occupational Behavior, 2(2), 99-113.
- Shanafelt, T.D., Hasan, O., Dyrbye, L.N., Sinsky, C., Satele, D., Sloan, J., & West, C.P. (2015). Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General US Working Population between 2011 and 2014. Mayo Clinic Proceedings, 90(12).
- Shakir, H.J., McPheeters, M.J., Shallwani, H., Pittari, J.E., & Reynolds, R.M. (2017). The Prevalence of Burnout Among US Neurosurgery Residents. Neurosurgery, 83 (3).
- Ensuring an Adequate Neurosurgical Workforce for the 21st Century. (December 19, 2012). Retrieved from https://www.aans.org/pdf/Legislative/Neurosurgery%20IOM%20GME%20Paper%20...
- Drummond, D. (2015). Physician Burnout: Its Origin, Symptoms and Five Main Causes. Fam Pract Manag. 22 (5).